MEDICARE: SE HEE MIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	141943	CT

General Provider Information

NPI Number	:	1073135505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SE HEE MIN

Provider Business Mailing Address
First Line	:	1817 NE 21ST ST
Second Line	:
City	:	RENTON
State	:	WA
Zip	:	98056-2614
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9116 GRAVELLY LAKE DR SW STE 107
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-3148
Country	:	US
Telephone Number	:	253-581-6106
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2020
Last Update Date	:	05/06/2020

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